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 News regarding Medicare/Mediaid's ruling in the US.

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Join date : 2007-12-09
Age : 57
Location : Near Ottawa, Ontario Canada.

PostSubject: News regarding Medicare/Mediaid's ruling in the US.   Fri Aug 22, 2008 4:15 pm

I'd like to pass on to you some recent news regarding Medicare/Mediaid's
ruling regarding hospital ruling regarding hospital acquired conditions; specifically DVT/PE.

Just happens that I will be having Hip Replacement Surgery in the coming

Tom Hogan
NATT Secretary and Treasurer

NATT is quite pleased that, on August 19, 2008, the Center for Medicare
and Medicaid Services (CMS) published regulations that categorizes hip
and knee replacement - associated DVT / PE as hospital acquired
conditions (HAC's). These HA's will be considered as "never events" in
the interest of patient safety in hospitals which means that
reimbursement will be denied as a penalty because DVT and PE should not
occur as the effectiveness of preventive measures has been well
documented. On July 31, CMS announced its intent to publish these
regulations which will go into effect October 1, 2008. Attached are CMS
July 31 announcement and excerpts of the final regulation that were
published in the August 19 Federal Register. The following link to
NATT's website provides some additional background concerning this
victory. (go to NATT Medicare / Medicare victory on
home page and click related stories.)

On June 12, 2008, NATT submitted recommendations regarding Medicare
reimbursement policies for preventable DVT/PE to the Center for Medicare
and Medicaid Services (CMS). (See attached.)

In summary, NATT urged CMS to deny reimbursement for preventable DVT/PEs
in selected instances and urged further review to expand reimbursement
denial when practitioners/hospitals do not follow established guidelines
to prevent and or treat clots. NATT also urged that reimbursement not
be denied where proper care was provided and other instances where clots
could not have been prevented. We also recommended incentives for
following best practices in these areas. It is our hope that
implementation of such policies will strongly encourage appropriate
treatment and prophylaxis for many patients at risk for DVT/PE. NATT's
Medical and Scientific Advisory Board and Randy Fenninger, our President
(and expert healthcare/reimbursement policy lobbyist) guided us in
shaping this policy.

As a result of this policy, many lives will be saved and
clotting-related morbidity will be reduced - this is central to NATT's
mission. It is also clear that much more needs to be done. Our
Washington Office will be following the implementation of the new
regulations and will be seeking to expand the definition of DVT / PE as
HACs in other areas where preventative measures should be taken.

Any comments or suggestions would be most welcome.

Alan Brownstein
Executive Director



The Centers for Medicare & Medicaid Services (CMS) announced today it is taking several actions to improve the quality of care in hospitals and reduce the number of “never events” -- preventable medical errors that result in serious consequences for the patient.

“Never events cause serious injury or death to beneficiaries and result in unnecessary costs to Medicare and Medicaid due to the need to treat the consequences of the errors,” said CMS Acting Administrator Kerry Weems. “The steps taken today reflect our strong conviction that these events, in fact, should be prevented, and our commitment to protecting Medicare and Medicaid patients from them.”

A final acute care inpatient prospective payment (IPPS) rule that went on display today at the Office of the Federal Register for publication August 1, 2008 updates Medicare payments to hospitals for fiscal year (FY) 2009 and provides additional incentives for hospitals to improve the quality of care provided to people with Medicare. As part of these quality of care incentives, the rule includes payment provisions to reduce never events that occur in hospitals.

The Final Regulation will be published in the Federal Register on August, 19, 2008.

The CMS press release is available at:

The IPPS rule will be posted at -

NCD Tracking Sheets:

c. Deep Vein Thrombosis (DVT)/
Pulmonary Embolism (PE)
In the FY 2009 IPPS proposed rule, we proposed DVT/PE as a candidate HAC. We solicited comments on each of the statutory criteria, with particular focus on the degree to which DVT can be diagnosed on hospital admission andcan be considered reasonably preventable.
DVT occurs when a blood clot forms in the deep veins of an extremity, usually the leg, and causes pain, swelling, and inflammation. PE occurs when a clot or piece of a clot migrates from its original site to the lungs, causing the death of lung tissue, which can be fatal.
VerDate Aug<31>2005 17:37 Aug 18, 2008 Jkt 214001 PO 00000 Frm 00048 Fmt 4701 Sfmt 4700 E:\FR\FM\19AUR2.SGM 19AUR2 ER19AU08.331</GPH>sroberts on PROD1PC70 with RULES

Federal Register / Vol. 73, No. 161 / Tuesday, August 19, 2008 / Rules and Regulations 48481
16 Hospital Compare available at the Web site: Reviewed
July 8, 2008.

Comment: The majority of commenters emphasized the inability todetermine whether DVT was present on admission. The commenters were concerned about the lack of a standard clinical definition and diagnostic criteria, as well as difficulty in identifying at-risk patients. One commenter suggested that nearly half of all DVT/PEs are asymptomatic on admission. One commenter explained that obtaining the most accurate results would require expensive diagnostic testing of all patients, implying that this strategy would not be cost-effective and would, therefore, be unreasonable.

Response: The commenters’ concerns about the ability to diagnose DVT do not preclude DVT/PE from being selected as an HAC, as the attending physician determines whether the condition was present on admission (‘‘Y’’ POA reporting option) or whether presence on admission cannot be determined based on clinical judgment (‘‘W’’ POA reporting option). Hospitals will continue to be paid the higher MS–DRG amount for HACs coded as ‘‘Y’’ or ‘‘W’’ (we refer readers to section II.F.8. of this preamble).

Comment: Regarding the preventability of DVT/PE, onecommenter cited reduction of DVT/PE occurrence through mentoring and onsite consultation as a particularly effective intervention strategy.

Response: We agree that the occurrence of DVT/PE can be significantly reduced through the use of intervention strategies, including mentoring and onsite consultation.

Comment: A large proportion of commenters underscored the importance of considering risk factors in weighing the degree of preventability. Commenters noted that common risk factors, some of which cannot be modified, include clotting disorders, obesity, hypercoagulable state, cancer, HIV, or rheumatoid arthritis.

Response: We agree with commenters that the risk factors of a typical patient are important to consider when weighing the degree of preventability as it applies to DVT/PE (discussion of risk adjustment in section II.F.9. of this preamble). Selecting DVT/PE for these procedures as an HAC will have the positive effect of encouraging attention to risk assessment prior to surgery. Further, conditions such as clotting disorders, obesity, hypercoagulable state, cancer, HIV, and rheumatoid arthritis are CCs or MCCs under the IPPS payment system that, when present on the claim, will continue to trigger the higher-paying MS–DRG. Thus, the usual presence of additional CC/MCCs on claims for these procedures serves as an ‘‘inherent risk adjuster’’ to payment for total knee replacement and hip replacement cases.

Comment: Although no commenters submitted quantitative data to establish a rate of preventability, many commenters noted that adherence to evidence-based pharmacologic and nonpharmacologic interventions will not prevent all DVTs. One commenter suggested that DVT/PE should only be considered for the HAC payment provision when a patient did not receive proper prophylaxis.

Response: The fact that prophylaxis will not prevent every occurrence of DVT/PE does not preclude its selection as a reasonably preventable HAC. Further, as discussed in section IV.B. of this preamble, the Reporting Hospital Quality Data for the Annual Payment Update program includes a process of care measure regarding venous thromboembolism (VTE) prophylaxis within 24 hours prior to or after surgery. An analysis of publicly available data on Hospital Compare indicates that the national rate for the VTE prophylaxis measure for the third quarter of 2007 is approximately 82 percent.16 We have concluded from these data that a significant number of patients are not receiving the recommended evidencebased prophylaxis. We further note that the statute does not require that a condition be ‘‘always preventable’’ in order to qualify as an HAC, but rather that it be ‘‘reasonably preventable,’’ which necessarily implies something less than 100 percent.

Comment: Commenters also noted that, in some cases, anticoagulation prophylaxis may be contraindicated based on individual patient factors, including an increased risk of bleeding in postoperative patients.

Response: We agree with commenters that, in some cases, anticoagulation prophylaxis may be contraindicated. However, we do not view this as precluding the selection of DVT/PE as an HAC, as evidence-based interventions beyond pharmacologic prophylaxis, such as mechanical prophylaxis and early movement, should also be applied.

Comment: Some commenters supported DVT/PE as reasonably preventable through the application of evidence-based guidelines for certain subpopulations, specifically following certain orthopedic procedures.

Response: We agree with commenters that DVT/PE is reasonably preventable in specific subpopulations, and we are therefore selecting DVT/PE following certain orthopedic surgeries, specifically certain hip and knee replacement surgeries, as HACs. Total knee replacement is a surgery performed to replace the entire knee joint with an artificial internal prosthesis because the native knee joint is no longer able to function, because it is very painful, or both, usually due to advanced osteoarthritis, and total hip replacement is the analogous operation involving the hip joint. Our decision may be construed as only applying to the MCC PE, rather than DVT/PE, following certain hip and knee replacement surgeries as HACs because of coding considerations. The MS–DRGs that these procedures typically map to do not currently split based on CCs, and DVT is a CC.

The following chart includes the codes that describe DVT/PE following certain orthopedic surgeries as an HAC:
Selected HAC Medicare data (FY 2007) CC/MCC (ICD–9–CM codes)
Selected evidence-based guidelines Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE)
—Total Knee Replacement.
—Hip Replacement.
4,250 cases ........................... $58,625/hospital stay.
DVT: 453.40–453.42 (CC) OR PE: 415.11 (MCC) or 415.19 (MCC) AND
Total Knee Replacement:
(81.54) OR
Hip Replacement: (00.85– 00.87, 81.51–81.52).
Available on the Web site:
Available on the Web site:
VerDate Aug<31>2005 17:37 Aug 18, 2008 Jkt 214001 PO 00000 Frm 00049 Fmt 4701 Sfmt 4700 E:\FR\FM\19AUR2.SGM 19AUR2 sroberts on PROD1PC70 with RULES
48482 Federal Register / Vol. 73, No. 161 / Tuesday, August 19, 2008 / Rules and Regulations
PULMONARY EMBOLISM (PE)ICD–9–CM codes Code descriptors 00.85 ........... Resurfacing hip, total, acetabulum and femoral head.
00.86 ........... Resurfacing hip, partial, femoralhead.
00.87 ........... Resurfacing hip, partial, acetabulum.
81.51 ........... Total hip replacement.
81.52 ........... Partial hip replacement.
81.54 ........... Total knee replacement.
415.11 ......... Iatrogenic pulmonary embolism and infarction.
415.19 ......... Other pulmonary embolism and infarction—other.
453.40 ......... Venous embolism and thrombosis of unspecified deep vessels of lower extremity.

453.41 ......... Venous embolism and thrombosis of deep vessels of
proximal lower extremity.

EMBOLISM (PE)—Continued
codes Code descriptors
453.42 ......... Venous embolism and thrombosis of deep vessels of distal lower extremity.
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